Indirect Treatment Techniques - Quick Notes

Indirect vs Direct Techniques

• Direct techniques move the area toward the restrictive barrier for treatment (e.g., Soft Tissue, Direct MFR, Articulatory, Muscle Energy, HVLA).
• Indirect techniques move the area away from the restrictive barrier for treatment (e.g., Indirect MFR, Counterstrain, Facilitated Positional Release, Still’s Technique, many functional techniques).

Myofascial Release (MFR)

• Definition: A diagnostic and treatment system described by A.T. Still; engages continual palpatory feedback to release myofascial tissues.
• Modes:
  • Direct techniques: engage a restrictive barrier until release.
  • Indirect techniques: find and engage the tissue’s position of ease.
• Fascia role: supports posture, protects, coordinates muscle action, aids circulation and lymphatics, helps homeostasis.
  • Key functions include maintaining alignment and enabling smooth tissue response to stress.
• Force effects in connective tissue (concepts):
  • Plastic deformation: new shape preserved after stress.
  • Elastic deformation: tissue returns to original shape.
  • Creep and hysteresis: time-dependent and energy-loss properties under load.
  • Stress–strain relationship and viscoelastic behavior.
• Piezoelectric properties of collagen:
  • Collagen discharges electrochemical signals when stressed, guiding remodeling and repair; signals indicate stress direction and magnitude.
• Mechanisms of action (broad):
  • Mechanical/viscoelastic effects; tissue remodeling; neural modulation; fluid dynamics; proprioception; anti-nociceptive effects.
• Activation forces in MFR (types):
  • Inherent (intrinsic) force: body’s tendency toward homeostasis.
  • Respiratory force: inhalation/exhalation cycles, breath-holding, coughing/sniffing to aid release.
  • Physician-guided force: guided positions following a shifting path of easy motion until dysfunction is released.
  • Springing/vibration: variable pressure/frequency to promote release.
• Indications and benefits: somatic dysfunction in myofascial tissues; connective tissue restrictions; asymmetry; improvements in motion, circulation, lymphatics, edema; normalization of neuroreflexive activity; supports visceral function.
• Indirect MFR technique (directions):
  • Engage the tissue in its ease with loaded, constant, directional force until release.
  • Directions: Superior & Inferior; Medial & Lateral; Clockwise & Counterclockwise.
• Contraindications for MFR (absolute vs relative):
  • Absolute: fracture near treatment site; absence of somatic dysfunction; lack of consent/cooperation; open wounds; infection; DVT/anticoagulation; neoplasm; recent surgery.
  • Relative: consider patient condition and risk.

Mechanisms and Background (Fascia, Force, and Remodeling)

• Function of fascia (why we treat): supports posture, coordinates muscle action, aids circulation/lymphatics, maintains homeostasis.
• Tissue response to load: stress–strain, creep, hysteresis, and viscoelastic adaptation.
• Piezoelectric signaling: mechanical stress influences cellular activity and guides tissue remodeling.
• Resulting physiological effects: improved interstitial flow, extracellular matrix reset, proprioceptive recalibration, and reduced afferent input leading to reflex relaxation.

Indirect MFR Indications/Contraindications (brief)

• Indications: somatic dysfunction in fascia, connective tissue restrictions, and symmetrically supporting motion with improved systemic function.
• Benefits: normalized motion, improved circulation/lymphatics, reduced edema/inflammation, healthier neuroreflexive balance.

Indirect MFR Technique (practical cue)

• Start at the tissue’s point of ease and apply a loaded, constant force until motion is restored.
• Directions to explore ease: Superior, Inferior, Medial, Lateral, Clockwise, Counterclockwise.

Counterstrain (Tender-Point–Based Indirect Approach)

• Definition: An osteopathic diagnostic/indirect treatment system using a position of spontaneous tissue release to treat a tenderpoint associated with somatic dysfunction.
• History: Developed from observations by Dr. Lawrence H. Jones in 1955; tenderpoints can be posterior or anterior and correlate with dysfunction.
• Tenderpoints: small, tense, edematous areas near bony attachments or in muscle/tendon/ligament fascia; palpated as locally tender, without radiating pain.
• Tenderpoint locations: near tendons/ligaments/fascia, muscle bellies, tendon insertions, thoracolumbar fascia, peritendinous areas, perimysium.
• Diagnosis approach: history and posture followed by locating tissue locations with tenderness and texture abnormalities; pressure to elicit tenderness approximates blanching of the diagnosing finger’s nail bed (no tenderness in healthy tissue).
• Comparison: Trigger points vs Counterstrain points differ in pattern, location, radiation, and response to treatment (Counterstrain points show no radiating pattern and no taut bands).
• Indications: somatic dysfunctions, especially with a neural component like hypertonic muscle; can be primary or adjunctive.
• Contraindications: Absolute (absence of somatic dysfunction, lack of consent, fracture, torn ligament); Relative (patient cannot relax, severe illness, vertebral artery disease, extreme osteoporosis, extension position contraindicated).
• Diagnosis workflow: assess history/posture, find tenderpoints, confirm with tenderness/texture, treat in position of ease, monitor and recheck.
• Steps to perform Counterstrain:
  1) Find a tenderpoint.
  2) Establish tenderness assessment (pain scale).
  3) Place patient in position of ease (approximate position, then fine-tune with small arcs to maximize ease, target >70% tenderness reduction toward 100%).
  4) Maintain for $(90 ext{ s})$ while monitoring.
  5) Return slowly to neutral and recheck tenderness.

Counterstrain Points and Diagnostic Mapping

• Points are consistent across patients and map to group III/IV afferents and receptors near tendons, ligaments, fascia, and muscle bellies.
• Dermographia is not present at counterstrain points.
• Diagnostic aids include tenderness location and texture changes rather than radiating pain.

Still Technique (Indirect to Direct Continuum)

• Concept: Still technique begins indirect (position of ease) and can transition to direct as tissue restrictions are engaged.
• Nature: A passive technique addressing arthrodial and soft tissue components of dysfunction.
• Historical context: Rooted in Still’s osteopathy with later historical recognition.
• Physiological mechanisms (brief): nociceptor/CNS repatterning, myofascial repair, vascular/immunologic changes; fascia-related memory and elastic properties.
• Still technique steps (condensed):
  1) Diagnose.
  2) Start indirect – move tissues into position of ease (away from barrier).
  3) Exaggerate – move further into ease to relax the myofascial elements.
  4) Apply a modest force vector (~$(5 ext{ lbs})$).
  5) Direct movement arc through the restrictive barrier toward release.
  6) Return to resting position and recheck.
• Similarities to other indirect techniques: shares “position of ease” at start with FPR and other indirect methods; Still’s allows greater exaggeration of ease than FPR; Still technique involves a later direct component.

Facilitated Positional Release (FPR)

• Definition: Indirect method of treatment developed by Stanley Schiowitz; goal to decrease tissue hypertonicity; adaptable to deep muscle involvement and joint mobility.
• Theoretical basis: gamma loop modulation (Korr) and reduced Ia input to the spinal cord via decreased spindle output after shortening occurs; aims to reduce segmental hypertonicity.
• Indications: acute or chronic somatic dysfunctions; somatic dysfunctions with neural components (hypertonic muscle); can be primary or adjunctive.
• Contraindications: Absolute (absence of somatic dysfunction, lack of consent, fracture); Relative (hernia/disc bulge, vertebral artery disease in extension, severe osteoporosis).
• Diagnosis: Focus on muscle hypertonicity and TART (tissue texture changes, asymmetry, range of motion, tenderness).
• Treatments: two forms
  • Tissue texture change treatment: flatten A-P curve, place into ease, apply a facilitating force, hold 3–5 seconds, re-evaluate.
  • Intervertebral motion restriction treatment: diagnose segment, flatten A-P curve, place vertebra to allow motion in all planes, apply force, hold 3–5 seconds, re-evaluate.

Still Technique vs FPR vs Counterstrain (quick cross-reference)

• Still: indirect-to-direct progression; passive; addresses arthrodial and soft tissue components; lengthened position of ease often followed by a direct release.
• FPR: indirect start; uses a short hold with a facilitating force; aims to reset hypertonicity with minimal tissue displacement.
• Counterstrain: continuous monitoring of tenderpoints; sustained position of ease for 90 seconds; primarily indirect with eventual release without forcing tissue through its barrier.

Quick reminders for last-minute review

• Indirect techniques start with the tissue in its ease; direct techniques end by moving through the barrier.
• Key tests of success: reduction in tenderness, improved range of motion, visible tissue relaxation, and recheck findings post-treatment.
• Commonly cited time and force references: hold times around $(90 ext{ s})$ (Counterstrain) and $(3-5 ext{ s})$ holds (FPR tissue texture changes) with modest forces like $(5 ext{ lbs})$ during Still’s technique.